Mitigating disrespect and abuse during childbirth in Tanzania: an exploratory study of the effects of two facility-based interventions in a large public hospital

Demographics

The mean age of women who were interviewed during community follow-up interviews was
29.7 years. Approximately 10 % were HIV positive and 17.5 % were nulliparous. The
majority were married (82.6 %), had at least a primary education (82.6 %), and had
completed at least four antenatal care visits for their most recent delivery (69.1 %).
Overall, these demographic characteristics were similar to those of women interviewed
during the baseline assessment, except for age (women interviewed for the evaluation
tended to be slightly older than women at baseline: 29.7 vs. 25.2 years old). Also,
some characteristics of women’s reproductive history in the baseline and evaluation
groups differed, such as parity (women at baseline were more frequently nulliparous
:36 % compared to 17.5 %), and coverage of antenatal care (57 % attended at least
four compared to 69 % at evaluation) (Sando, et al. The prevalence of disrespect and
abuse during facility-based childbirth in urban Tanzania, Forthcoming). Amongst women
who were observed during labor and delivery, approximately half had one or two previous
deliveries and 7 % were HIV positive.

The mean age of providers interviewed was 35.2 years, and 89 % were female. Approximately
80 % of respondents were nurses/nurse-midwives and 14.5 % included other clinical
staff, such as medical officers and assistant medical officers. All wards of the maternity
block, including antenatal (18 %), labor (36 %), and postnatal (33 %) were represented
in our population and the median time respondents had spent working in their respective
ward was one year.

Intervention outputs

Open Birth Days

This intervention showed high acceptability among both women and providers. All women
who were invited to participate in OBD consented. During the interviews conducted
by study staff immediately after OBD sessions, all respondents expressed satisfaction
with the intervention, with several commenting that it should be expanded to all other
delivery facilities in Dar es Salaam. Among community follow-up interview respondents
who had participated in OBD, 92.6 % said that they found the session “very helpful”
and 96.3 % said they would be “very likely” to recommend to other women in their community
to attend an OBD session before they deliver.

We collected feedback from health care providers midway through the implementation
period, including the nurse in-charge of the reproductive and child health clinic,
the matron of the maternity block, and the head of obstetrics and gynecology. All
informants indicated that they were satisfied with OBD and noted that the intervention
was manageable with their other duties and that they liked the opportunity to interact
with their patients. Importantly, hospital staff said that the information provided
during OBD was useful to both women and providers, particularly in reinforcing ethical
codes and principles and facilitating more informal interactions between women and
providers.

Respectful maternity care workshop

Staff perceptions of the workshop were positive. Observations by study team members
and feedback from key informants found that, in all of the workshop sessions, there
was a high level of participant engagement and interaction. Additionally, at the conclusion
of the study, providers, administrators, and municipal officials all expressed enthusiasm
for the training and suggested that the intervention should be included in future
facility budgeting activities and scaled throughout the municipality.

At the conclusion of the workshops, representatives from each group came together
to generate one unified action plan for the maternity block, including the antenatal,
labor, and postnatal wards. This action plan was approved by the hospital management
team and integrated into routine facility processes throughout all wards of maternity
block. In addition to addressing facility barriers to respectful care, the action
plan was designed to empower health care providers and to improve their feelings of
self-efficacy and ability to enact change within their workplace. Items in the action
plan were contained to activities that staff could conduct on their own, through teamwork
and active involvement, without substantial additional resources. One of the primary
objectives of the RMC Workshop action plan was to generate conversation about creating
a culture of respect at the hospital. Thus the action plan was used as a tool at department
meetings, and provided opportunities for staff of all cadres to discuss issues of
patient care.

Throughout the implementation period, progress was made on several items from the
facility-wide action plan, including:

A new reporting structure was put in place to speed up the payment of overtime allowances.
Before the intervention, overtime payments were often delayed by up to six months;
this delay decreased to six weeks by the end of the intervention period.

Two staff recognition events were held to improve staff motivation. Staff were selected
for recognition based on a set list of criteria determined by RMC Workshop participants,
including punctuality, number of deliveries conducted, relationships with other staff,
team work, and good interpersonal care. Recipients were rewarded with certificates
and small gifts, and plans are in place for these events to occur at least annually.

To improve staff morale, a system was developed to ensure that bread and tea were
always available to staff in the break room.

Issues related to teamwork, communication, provider-patient relationships, and patient
rights were discussed weekly at departmental meetings throughout the intervention
period.

Curtains and screens were procured—and existing supplies repaired—to ensure that
all beds had a functioning partition to provide privacy.

To increase the number of staff per shift, nurse shifts were increased from eight
to twelve hours. This was initially acceptable to staff, but eventually led to overwork
and complaints and the shifts were reversed to eight hours.

Posters displaying the Universal Rights of Childbearing Women in Kiswahili were displayed
in the antenatal and labor wards.

Staff identified the need to receive feedback from patients more regularly, and a
brief and confidential exit survey was designed and piloted in October 2014. The goal
of the surveys was to compile feedback quarterly and share with staff during department
meetings.

A brief survey tool was designed to gather staff feedback on supportive supervision,
and hospital administrators are continuing to plan methods to improve supportive supervision
at the facility.

Proximal outcomes

Patient knowledge

Pre-post tests administered around the Open Birth Day sessions found a notable increase
in patient knowledge of many of their rights during labor and delivery (Table 3), including the right to consent (from 30.1 to 57.8 %), the right to be free from
physical abuse (from 79.5 to 86.9 %), and the right to privacy (68.2 to 81.9 %). Knowledge
of some rights, such as the right to dignified care (from 88.0 to 88.8 %), the right
to information (95.1 to 96.7 %), and the right to appropriate and timely care (from
96.4 to 96.2 %), was high at baseline and showed little change. Women’s knowledge
of the labor and delivery process also improved through OBD; pre-post tests documented
a 13.0 % increase (from 77.8 to 88.0 %) in knowledge of where to check in at the facility
when in labor and a 64.7 % increase (from 27.1 to 44.7 %) in knowledge that it is
best to move around during labor.

Table 3. Changes in patient knowledge (N?=?362)

Provider perspectives of patient preparedness shifted over the course of implementation.
During structured provider interviews in the evaluation, 65.5 % of providers said
that they could tell whether a woman had attended OBD when she comes to deliver. The
most common reasons cited included: the patient knows to bring all emergency supplies
she may need (61.1 %), the patient knows where to go for check in and what documents
she will need (75.0 %), the patient knows where to wait until she is moved to the
next area (69.4 %), and that the woman understands her rights as a patient (86.1 %).
Notably, 100 % of providers interviewed during the evaluation who had participated
in OBD agreed that the activity prepared women for labor and delivery.

Provider knowledge

The intervention package increased aspects of provider knowledge of their code of
conduct, ethics, and patient rights. The RMC Workshop pre and post-test data (Table 4) documented a 5.4 % increase in providers who stated that “disrespect and abuse during
maternity care is a human rights violation” and a 6.8 % increase in knowledge that
disrespect and abuse is a global problem. Further evidence suggests that provider
knowledge of informed consent increased, with the RMC Workshop post-tests documenting
a 17.3 % reduction in providers who said that it was “safer to withhold information
from less educated women.” Two elements of provider knowledge—including the importance
of confidentiality and defining communication—decreased slightly from pre- to post-test.
Overall, during structured provider interviews during the evaluation, 79.1 % of providers
who participated in the RMC Workshop stated that the intervention allowed them to
“understand much better” what constitutes patient rights.

Table 4. RMC Workshop Pre-Post Tests (N?=?76)

Patient attitudes and perceptions

Patient attitudes about childbirth at the study facility changed during the intervention
period. OBD pre-post tests found that 13.4 % of participants said they felt more comfortable
about their upcoming delivery at the study facility after their participation in the
program, and the proportion of respondents who said they felt “very comfortable” increased
from 67.0 to 73.4 %. Community follow-up interviews four to six weeks after delivery
with women who had attended OBD found that 77.8 % of respondents said that participation
in OBD made them feel “much more prepared for delivery” while 14.8 % said they felt
“somewhat more prepared.” Similarly, 88.9 % of respondents said that the OBD made
them feel more comfortable about their delivery at the study facility.

Provider attitudes and perceptions

Data from multiple tools indicated that providers’ understanding of their patients’
backgrounds and empathy for their patients increased over time. The RMC Workshop pre-post
tests (Table 4) found a 36.9 % increase in providers who said they agreed with the statement “I
have a good understanding of my clients’ backgrounds” and a 10.8 % increase in providers
who agreed that “I am able to empathize with my clients.” In the evaluation, 75 %
of providers who participated in the RMC Workshop “strongly agreed” that the workshop
“helped me to improve my interpersonal relationships with clients in the facility.”

Provider attitudes regarding the care provided at the study facility also changed.
Results from the RMC Workshop pre-post test indicate that providers’ perceptions of
client satisfaction with care at the facility decreased after participation in the
workshop (Table 4). Additionally, there was an 8.6 % increase in providers stating that they wished
to develop stronger relationships with colleagues and a high percentage (97.3 %) of
providers said that building strong teams is important for delivering high quality
care. At both pre and post-test, all providers agreed that there is a need to improve
attitudes towards clients.

Patient-provider communication

During structured provider interviews, 98.2 % said that participation in Open Birth
Days improves communication between patients and providers. Additionally, there is
evidence that this improved communication continued during labor and delivery as observers
noted that providers were more welcoming to women than during baseline and more likely
to introduce themselves. Although we did not specifically assess communication between
providers and administrators, anecdotal feedback from staff members suggests that
the dialogue and communication about respectful maternity care improved. When interviewed
during the project evaluation, 78.2 % of providers strongly agreed that their facility
has good teamwork between cadres compared with 11 % at baseline.

Distal outcomes

Empowered patients

In addition to being more prepared for delivery and more knowledgeable about their
rights, women felt more empowered about their childbirth experience. Nine of the 22
respondents (40.9 %) in the short open-ended interviews with OBD participants remarked
that OBD was the first time they had heard anything about their rights during labor
and delivery. In particular, two of these respondents noted that they learned for
the first time that their consent is required for any procedure and that they can
say “no” if/when they do not want or understand a proposed procedure. This increased
confidence and knowledge was also manifested in women’s actions. For example, during
the baseline assessment, no participant who reported experiencing disrespect and abuse
took any actions to rectify or report the situation, while during the evaluation,
10 % of women who attended OBD and reported feeling disrespected during labor and
delivery formally filed a complaint.

Provider job satisfaction

The RMC Workshop pre-post tests found that providers had increased feelings of efficacy
and empowerment (Table 4), including the ability to solve problems at work and a belief that their own attitudes
can affect both the quality of care they provide and their job satisfaction. Notably,
there was a 48.6 % decrease from pre- to post-test in providers who agreed that there
is nothing they can do to improve their job satisfaction.

Structured provider interviews during evaluation showed that 70.8 % of providers who
had participated in the RMC Workshop “strongly agreed” that they were better able
to communicate with their supervisors about things they would like to change in their
role, and 66.7 % said that they were better able to communicate with supervisors about
facility-related issues after completing the workshop. Additionally, 65.2 % of providers
said that the process of developing and implementing the RMC Workshop action plan
changed their perception about how they were able to change facility norms and procedures,
and 70.9 % said that the Workshop changed the way they managed job stress.

During structured provider interviews, 41.7 % of providers who participated in the
RMC Workshop said that the process of developing and implementing the action plan
changed their job satisfaction. As shown in Table 5, many elements of job satisfaction improved over the course of the intervention period.
Providers’ described an increased sense of autonomy, improved perceptions of management
and supervisors, and improved relationships between staff members.

Table 5. Provider job satisfaction (Baseline N?=?50; Evaluation N?=?55*)

Improved patient-provider interactions

The package of interventions also had an effect on the quality of patient-provider
interactions. Women’s responses during short open-ended interviews after OBD sessions
indicate that participants were able to view and interact with providers “as people”
(verbatim term used by women), likely as a result of having a venue to engage with
providers in a more informal manner with more opportunities for dialogue than the
formal antenatal care visit. A few participants interviewed commented that they liked
the way that nurses provided education and spoke to them during these sessions, with
one woman saying the most important thing she learned at OBD sessions was about “the
good collaboration of the nurses” with patients.

Additionally, providers indicated that they felt an increased responsibility after
the interventions to provide high quality, respectful care to their patients. All
providers (n?=?25) who were interviewed at evaluation and had participated in the RMC Workshop
reported that the Workshop changed the way they thought about and interacted with
their patients. When asked to elaborate, provider responses included:

“It [RMC Workshop] has helped, it reminded us to provide the services they need.”

“I have managed to keep myself good/updated because I must give mother her rights,
I might give birth at the hospital too so the rights should be adhered to.”

“How to talk to patients with love together with listening to the client.”

“Because I know clients’ rights and she is aware of her rights, too, there are significant
changes.”

“Using good language brings peace and joy to the patients.”

Patient satisfaction and perceptions of quality

Patient satisfaction with services received and their perceptions of quality improved
substantially from baseline. During community follow-up interviews, 75.8 % of women
reported being very satisfied with their delivery experience compared to only 12.9 %
at baseline (Fig. 2). Similarly, at the time of evaluation, 22.8 % of women rated the respect shown to
them by providers as “excellent” compared to none at baseline. At baseline, no women
rated the quality of care they received as “excellent” and only 2.9 % gave a “very
good” rating; at the time of evaluation, these frequencies increased to 22.8 and 40.3 %,
respectively. Finally, patient satisfaction with the way that health care services
were provided at the study facility also improved, with 76.5 % of women reporting
“very satisfied” at the evaluation compared to 10.0 % at baseline.

Fig. 2. Patient perceptions of satisfaction with delivery and health care services, quality
of care, and provider respectfulness. Light gray bars indicate baseline community follow-up responses (N?=?70) and dark gray indicate evaluation community follow-up responses (N?=?149)